Healthcare Provider Details

I. General information

NPI: 1770112765
Provider Name (Legal Business Name): MARYAM A AL UBAIDI DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2020
Last Update Date: 08/31/2021
Certification Date: 08/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6660 LONE TREE WAY STE 7
BRENTWOOD CA
94513-5310
US

IV. Provider business mailing address

1555 RIVIERA AVE APT 619
WALNUT CREEK CA
94596-7312
US

V. Phone/Fax

Practice location:
  • Phone: 925-513-8363
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDDS106248
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: